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City on a Hill, a nonprofit that holds a free monthly clinic, is housed in the building at N. 23rd St. and W. Kilbourn Ave., which used to be a hospital. Since 1988, Milwaukee County has lost its public hospital and five city hospitals.

Poor Health | Special Report

Hospitals, doctors moving out of poor city neighborhoods to more affluent areas

Hospitals and family doctors, the mainstays of health care, are pulling out of poor city neighborhoods, where the sickest populations live.

Poor Health

An occasional series

These stories are the first in a series produced by the Pittsburgh Post-Gazette and Milwaukee Journal Sentinel in connection with the O'Brien Fellowship in Public Service Journalism at Marquette University.

A Pittsburgh Post-Gazette/Milwaukee Journal Sentinel analysis of data from the largest U.S. metropolitan areas shows that people in poor neighborhoods are less healthy than their more affluent neighbors, but more likely to live in areas with physician shortages and closed hospitals.

At a time when research shows that being poor is highly correlated with poor health, hospitals and doctors are following privately insured patients to more affluent areas rather than remaining anchored in communities with the greatest health care needs.

The Post-Gazette/Journal Sentinel analysis shows that nearly two-thirds of the roughly 230 hospitals opened since 2000 are in wealthier, often suburban, areas.

A falling number of hospitals

After peaking in the 1970s, the number of hospitals in the cities that anchor America’s largest metropolitan areas has fallen by nearly 46%.

The economics of medical care in the United States has made poor patients the ones no one wants to treat.

As health systems open those facilities, they have been closing their urban counterparts. The number of hospitals in 52 major cities in the United States has fallen from its peak of 781 in 1970 to 426 in 2010, a drop of nearly 46%, according to a separate study.

Most of the facilities closed were small to mid-size community hospitals in poor urban neighborhoods and public hospitals, leaving many low-income neighborhoods with no safety-net hospital.

New York City's boroughs have lost more than 20 hospitals since 1990. Detroit has gone from dozens in the 1960s to four.

In Braddock, Pa., a distressed community near Pittsburgh that has lost most of its population since the collapse of the steel industry, residents fought a long battle against the closure of their local hospital. The University of Pittsburgh Medical Center shut down its Braddock facility in 2010 and protesters gathered in the street as the building was razed months later, tolling a bell for the 104-year-old institution.

Since 1988, Milwaukee County has lost its public hospital and five city hospitals.

Photo Gallery

Kelvin Bohannon has a blood sample taken by nurse Alyssa Sekadlo at City on a Hill, a faith-based nonprofit organization located in the heart of Milwaukee, and working as a catalyst to bring transformation to individuals, families and neighborhoods in the central city. They offer a wide variety of services using hundreds of volunteers to provide a health care clinic with multiple functions as well as a food pantry, and meal program.

One of those is the former Good Samaritan. A small nonprofit called City on a Hill now operates in a wing of the building at N. 23rd St. and W. Kilbourn Ave. Once a month, when the agency hosts a free clinic on a Saturday, a line forms more than an hour before it opens and stretches down the block.

The closures have been going on for decades.

Between 1990 and 2010 alone, 148 nonprofit hospitals closed in the largest American cities, along with 53 for-profit hospitals.

In addition, five public hospitals closed, according to Alan Sager of Boston University, who has tracked and studied hospital closures in the United States. His research shows it's not just poor performing hospitals being closed; the ones that shut down often are rated as being more efficient than those that remain open.

"In a competitive free market, efficient hospitals would be likelier to survive," he wrote in a paper summarizing some of his research results. "That hasn't happened, providing evidence that no such market is present."

When communities lose hospitals, they lose doctors, too.

The newspapers' data analysis shows that doctors are scarcer in poor areas: More than half of the federally designated "primary care shortage areas" in the 52 major metropolitan areas fall in census tracts of highest poverty. Those areas also tend to have higher than average populations of people with disabilities.

These are typically neighborhoods where people are isolated by poverty. They are less likely to have jobs, less likely to have vehicles and access to healthy food, and more likely to face violence in and outside their homes.

As the presence of health care providers in low-income neighborhoods decreases, a growing body of evidence shows that poor people are more likely to be in poor health — indeed, poverty itself can make people sick.

Video

Diane De La Santos, executive director of City on a Hill, talks about generational poverty and the challenge it presents to the Milwaukee nonprofit as it works to fulfill its mission.

Think of a child with asthma living in a mold-filled apartment; a man with an infected foot living on the streets and sleeping in his dirty, wet shoes; or a diabetic without a refrigerator to store her insulin.

Mary Mazul, director of population health management and integration at Wheaton Franciscan Healthcare in Milwaukee, described a conversation with a doctor she knows who works with mostly poor patients who told her: "Mary, I'm a good doctor but my outcomes aren't so good."

"Health care can't fix poverty, homelessness, racism," Mazul said.

Early death is the simplest measure of compromised health.

A Centers for Disease Control and Prevention study of U.S. counties conducted by University of Wisconsin researchers showed that the overall rate of death before 75 was 417 per 100,000. In low-income counties, the average was 480; in higher-income counties, the average was 345. The premature death rate was 39% higher in the poor counties that have been losing hospitals and doctors.

Disability rates also are higher among low-income residents. The Post-Gazette/Journal Sentinel analysis of U.S. Census data shows that in the lowest-income areas, an average of 12% of the population ages 5 to 64 reported having a disability. In the highest-income areas, the average is 5%.

Income tied to health

Those with higher incomes are less likely to report poor or fair health than those with lower incomes. This is true across racial and ethnic groups.

Percentage of people reporting poor/fair health by income as a percentage of the federal poverty level*

Source: Overcoming Obstacles to Health in 2013 and Beyond, Robert Wood Johnson Foundation Commission to Build a Healthier America

It is those higher-income areas, where people are healthier and mobile, that are most likely to get new hospitals. At the same time that UPMC was closing its hospital in Braddock, it was constructing a new $250 million hospital in Monroeville, a suburb where the average household income is more than twice as high.

"To me it's like free-market fire departments," said Robert Connolly of Common Ground, a Milwaukee community organization that started a health care cooperative last year. "Would anyone advocate building one on a corner across from another one to compete for fire business?"

Or closing down a fire station in a neighborhood with a higher rate of fires?

Created to serve the poor

The past few decades of closures completed a chapter in which the founding principle of hospitals in the United States was stood on its head.

Most hospitals began as charitable institutions dedicated to the poor, often started by religious groups or social reformers.

In Milwaukee, Lutheran deaconesses converted a hilltop farmhouse into a hospital for the poor in August 1863. It is the ancestor of the complex on Kilbourn Ave. that is now home to the nonprofit City on a Hill.

Interactive Map

Explore where hospitals have opened and closed, how many people live in poverty or with disabilities, and federally-designated primary care shortage areas.

Originally named Milwaukee Hospital, it was often called "The Passavant" after William A. Passavant, a Pennsylvania-born Lutheran minister who founded hospitals, orphanages, seminaries and colleges across the country. Passavant brought German deaconesses to the United States to replicate the medical training and hospital model established in Dusseldorf, spreading the best care practices of the day. He established hospitals, missions, orphanages and other social welfare institutions in New York, Pennsylvania, Wisconsin and Illinois.

He traveled to Milwaukee to work with local leaders who wanted to establish a hospital for the poor. Four Milwaukee doctors volunteered their services.

"At that point there was nothing here," said Diane De La Santos, executive director of City on a Hill. "It was all volunteer. The director was a pastor."

Individuals and congregations contributed to the effort, sponsoring beds or making donations of livestock or ice for the icehouse.

Around the country, dozens of similar institutions were founded. Look on the website of a typical health care giant and you'll find a version of the humble beginnings story:

In Buffalo, N.Y., Sister Ursula Mattingly — "one of God's trouble shooters" — was the first president of the Sisters of Charity Hospital established in 1848. It is now part of the Catholic Health system, a network of hospitals and clinics that serves western New York.

In Washington Territory in 1856, Mother Joseph of the Sacred Heart arrived to find "a new world of physical hardships" where there were no hospitals "and little in the way of charitable services for those suffering the misfortunes of life on the frontier." She established the hospital that eventually expanded into today's Providence Health & Services, an $8.7 billion health care system with facilities in Washington, Oregon, Alaska, California and Montana.

In the 19th and early 20th centuries, local governments — often counties — began to open public hospitals, also designed to serve the poor.

Most hospitals remained charitable institutions, but many began to accept paying patients as well. At Milwaukee Hospital, the first noncharity patients were admitted in 1873, at the rate of $5 per week. By the 1920s, hospitals served affluent as well as poor patients; medical schools became well established; and the American medical profession grew more powerful and prestigious.

In 1863, a small group of Lutheran deaconesses converted a farmhouse on a hill into a hospital for the poor. Over the years, it grew into a major operation west of downtown, and faced a series of mergers until it closed in 1998 amid financial difficulties. Today it is again home to a small nonprofit operation — City on a Hill, which offers a once-a-month free health clinic for the poor. Trace the building’s history through photos

A closer look at charity care and hospital profits

An analysis of hospital charitable care done by Modern Healthcare, a website that focuses on the hospital industry, found that the profits for tax-exempt hospitals exceeds the amount dedicated to charitable care. Even when other charitable factors are considered, the percentage is low — and most fall at the low end of the spectrum. The analysis was based on 2009 tax filings by tax-exempt hospitals.

Source: Modern Healthcare analysis, GuideStar data

The advent of private and public insurance reshaped the economics of health care.

During the Great Depression, administrators at Baylor Hospital in Dallas created the "Baylor Plan" — the first prepaid hospital insurance plan in the United States and predecessor of Blue Cross. Insurance for physicians' services also was developed in the 1930s.

The success of these programs encouraged more insurers to enter the health care market, and a labor shortage during World War II led to health insurance becoming part of many benefits packages, spurred by government tax incentives. Employers found that offering a health insurance package was a way to attract workers, and the federal tax write-off companies got for providing the benefit gave an incentive to make it a regular practice.

The entry of the government in the health insurance market with Medicare and Medicaid in the 1960s put many more Americans on an insurance plan, and more and more employees had private insurance through their employers.

By 1968, 80.8% of Americans had health insurance coverage, according to a statistical report published by the CDC.

"Our whole pricing system is illogical and unnecessarily complex," said George Brown, CEO of Legacy Health Care in Portland, Ore. "It's a system created by the bright idea during World War II of giving employers tax breaks."

That created new incentives and erased others.

Because a third party was paying, patients weren't deterred by the normal market mechanism — cost. And because health care providers were being reimbursed on a fee-for-service basis, they had little incentive to keep those costs down. Health care got more and more expensive. It also became lucrative for many providers and insurers, spawning a booming — and competitive — new industry. In the 1960s, the number of hospitals climbed, reaching its peak in 1970.

The evolution of health care in the United States

Interactive Timeline: American health care has gone from small hospitals focused on charity care to sprawling systems that increasingly are pulled to wealthy areas. This timeline looks at the changes.

Those structural economic changes meant hospitals got most of their revenue from selling specific services to private and government insurers rather than seeking donations and endowments to finance general care for whoever needed it, said Martin Gaynor, E.J. Barone professor of economics and health policy at Carnegie Mellon University.

"If the way you survive is by selling stuff, why are you going to behave differently from other big businesses?" Gaynor said.

Business boomed and hospitals expanded as insurance reimbursement rewarded tests, treatments and hospitalization.

The Milwaukee Hospital complex, which changed its name to Lutheran Hospital in 1966, continued to expand, with additions in 1970 and 1974.

Hospitals competed with one another to get patients, and began to acquire or merge with other hospitals and to buy physician practices to get their patients.

But even as hospitals added beds, technology and changes in Medicare were reducing the need for them. In the 1980s, Medicare switched to paying a fixed amount for specific services. This gave hospitals an incentive to send patients home as quickly as possible, since they got paid the same whether a patient stayed three days or seven days after a given procedure.

Advances in technology made it possible for outpatient care to replace inpatient care for many procedures. The demand for health care services continued to grow, but many hospitals struggled to fill their beds. That led to chaotic patterns of growth and retraction.

Health care experts recognized that competing hospitals were overbuilding and duplicating services and expensive equipment, which increased the costs of care. Nevertheless, expansion continued across the nation. When the supply exceeded demand, more mergers, acquisitions and closures resulted.

Mergers continued as struggling systems sought to survive by joining forces and powerful systems absorbed hospitals to gain market share. Weaker hospitals in poor neighborhoods often merged and then were shut down as "campuses" of bigger systems.

In Milwaukee, that played out in the 1980 merger of Lutheran and Evangelical Deaconess hospitals; the new institution was called Good Samaritan.

In 1984, Good Samaritan merged with St. Luke's; the Deaconess campus was closed and its buildings razed the following year.

Good Samaritan continued to buy properties and renovate its Kilbourn Ave. location. It merged with Mount Sinai in 1987 to create the Sinai Samaritan Medical Center based on N. 12th St. The Kilbourn Ave. complex — 10 blocks away — become the "west campus."

After three mergers in seven years, the system, which had been renamed Aurora Health Care, announced a three-year consolidation plan in 1988. It called for a reduction in beds from 913 to 581.

Within a decade, the west campus was shut down and the buildings were boarded up.

Added challenges

Health care providers and public officials often argue that the closure of a hospital in a dense urban area with other health care facilities doesn't have an impact on access to care for patients.

How we analyzed the data

The economics of medical care in the United States has made poor patients the ones no one wants to treat.

To examine the changing landscape of hospitals in large metropolitan areas, the Milwaukee Journal Sentinel and Pittsburgh Post-Gazette used Provider of Service files from the Centers for Medicare and Medicaid Services. The files, one dating from 1991 and another from 2013, provide snapshots in time of the locations and services offered by the hospitals that were registered with CMS at the time.

The analysis focused on short-term acute care centers — that is, hospitals with emergency rooms — in metro areas with at least 1 million population.

For measures of poverty, median income and disability, the newspapers used the five-year American Community Survey from the U.S. Census bureau. ZIP code tabulation areas were assigned to each hospital based on physical location, then compared to the broader metro area.

The newspapers also examined primary care physician shortage areas using data from the U.S. Health Resources and Services Administration. Geographic areas, as well as populations of people, can be considered to be in a shortage area if there are fewer than 1 primary care physician per 3,500 people. In areas of greater need, that figure is 1 doctor to 3,000 people.

Aurora officials said at the time of the west campus closure that with another Aurora facility so close, residents in the neighborhood of the Kilbourn campus still had a local hospital.

"Many rich white people seem remarkably stoic in the face of hospitals closing in African-American neighborhoods," said Sager, professor of health policy and management at the Boston University School of Public Health.

But the fact that urban dwellers have hospitals within reach doesn't mean they get what they need to be healthy or that closures don't affect their neighborhoods.

With the closure of the facility on Kilbourn Ave., a community in which most residents live below the poverty line lost an institution that provided jobs and customers for area businesses. And crucially, it lost doctors.

"If you looked back even a hundred years you would see doctors everywhere — following the population," Sager said. "But doctors have become much more geographically concentrated. They are no longer in rural areas, in urban areas. They are in suburban areas. When you lose the building you lose the doctors. That makes it hard to have legitimate medical care."

The federal government designates areas with fewer than one physician per 3,500 residents as "health professional shortage areas." The Post-Gazette/Journal Sentinel data analysis shows that the majority of those are in urban poverty corridors; most of the rest are in rural areas. And those "health care deserts" expand when hospitals close.

The residents — less likely to have cars — often lack access to family doctors, as well as dentists, psychologists and psychiatrists.

The physicians who remain in poor neighborhoods face added challenges.

Patients have lower incomes so are less able to pay for services out of pocket, said Darrell Gaskin, deputy director of the Hopkins Center for Health Disparities Solutions at Johns Hopkins Bloomberg School of Public Health. Doctors must deal with reimbursements under Medicaid that are lower than those from private insurers or Medicare.

"The supply of physicians and other health care providers in minority neighborhoods may be affected by lower quality of community amenities," Gaskin said. Lack of medical laboratories, medical supply companies, financing and credit for small business all act as barriers, he said, and drive up the cost of operating a practice.

Meanwhile, medical students facing education debt, which has soared in recent decades, are more likely to choose to enter higher-paid specialties, such as anesthesiology or oncology.

Two-thirds of U.S. physicians are specialists, well above the level in other rich democracies, where roughly half fall into that category. The United States has only about half as many family doctors per thousand people as other developed countries.

The number of medical students entering family practice training dropped by 50% between 1997 and 2005, according to American Academy of Family Physicians data. Most now become specialists, who are more likely to be affiliated with large hospitals where most patients are privately insured.

"I've worked at six different Milwaukee clinics that closed, including a clinic for the homeless and several low-income neighborhood facilities," said Bonnie Tesch, an Aurora physician who is the volunteer medical director of the clinic run by City on a Hill. "Usually it was because of political things, funding.

"The last one, honestly, no one told me it was closed. I arrived one day and there was a sign on the door, and that's how I found out, like the patients."

Jeff Smith, chief clinical officer at Aurora, said operating in low-income neighborhoods is a major challenge for health care systems. Under the current system, he said, "it's a burden that the health systems alone cannot meet. It's really going to require the community coming together to meet those needs. Certainly the health systems are part of that, but this is really a problem that's big enough that the health systems themselves can't fix it."

Aurora Sinai is the only hospital left in the downtown area, he said, and it bears a huge burden in caring for the large number of poor patients there.

Aurora officials said its network of clinics that serve low-income neighborhoods, including Walker's Point Clinic, a large free clinic south of downtown, help fill the gaps in care. Programs such as parish nurses, hospital-based and free-standing clinics, school initiatives and community outreach are part of the mix at Wheaton Franciscan Healthcare, Columbia St. Mary's and Froedtert Health as well.

Smith said large health care systems like Aurora have to use their profitable hospitals to subsidize remaining city hospitals like Sinai, which operates at a loss every year.

Officials from Milwaukee's big health care systems all said they worry every time they hear a city hospital might close, because it would mean the load of uninsured or Medicaid patients would increase for the remaining ones.

The shifting economics of health care pulled hospitals from what had once been their primary purpose: serving the needy. As hospitals saw poor patients as toxic to their financial health, the percentage of charitable care given by U.S. hospitals dropped.

Video

Diane De La Santos, executive director of City on a Hill, talks about what led to the creation of the nonprofit, which operates in a former hospital west of downtown Milwaukee.

A 2013 New England Journal of Medicine study found that nonprofit hospitals provide, on average, 7.5% of their operating expenses for IRS-defined community benefits. Such community benefits include education and other activities not related to the free or reduced-cost service many associate with the idea of charitable care. The average spent on free or reduced-cost care is around 2%.

Systemwide, Aurora spends 2.2% of its net revenue on community benefits, 1.1% on charitable care. Aurora Sinai — which lost $15.3 million in 2012 — spends 2% of revenue on charitable care.

It's difficult to say how much Aurora saves due to its tax-exempt status, but a 2008 study by the Institute for Wisconsin's Future estimated the Sinai and St. Luke's facilities would have owed $11 million in property taxes in Milwaukee alone for a single year.

The majority of U.S. hospitals are nonprofit and retain tax exemptions based in large part on the premise that they provide services to the community. But free or reduced-cost care for the poor is now a very small part of what hospitals do.

In a little over a century, poor people have gone from hospitals' reason for being to the patients hospitals most want to avoid.

City on a Hill sees need

Two years after the former hospital on Kilbourn Ave. closed, the Urban Ministry Center, a small nonprofit affiliated with Parklawn Assembly of God church, joined with a national group called Convoy of Hope to organize a community event that included a job fair, health screenings and activities for children.

De La Santos, then a vice president of public affairs at Aurora Health Care, learned the group was searching for a place to hold the August 2000 event and helped it get use of the parking lot of the vacant hospital complex.

Video

Diane De La Santos, executive director of City on a Hill, talks about how the 2000 Convoy of Hope event on the grounds of a closed hospital on Milwaukee's west side, demonstrated the urgent need for services for those in poverty.

Eight thousand people showed up.

The big turnout made it clear the community had many unmet needs and that the empty hospital could have another life, De La Santos said. Four months later, Aurora transferred its four remaining buildings — 321,000 square feet — to the nonprofit now called City on a Hill.

De La Santos said she and others saw "the inevitable deterioration of a neighborhood when you pull out a large institution like that."

She started as a board member in 2001, then became a loaned executive two years later after the group had difficulties and went into debt.

By that time, "I was at a place in my life where I was more concerned with the significance of my life than with my career." She left Aurora to lead City on a Hill.

City on a Hill runs on less than $900,000 a year; with 14 full-time employees and one part-timer, it relies heavily on volunteers. De La Santos does the grant-writing and fundraising herself.

Video

Diane De La Santos, executive director of City on a Hill, talks with volunteers about the mission of her nonprofit group, which operates in a former hospital on Milwaukee's west side.

City on a Hill has chosen to focus on youth programs because that is where it sees the best chance of having an impact, De La Santos said. But the health needs of the community are great, and the monthly clinic has limited capacity. It serves an average of 306 patients a month in a neighborhood where 64% live below the poverty line.

In the city's far western and far northern suburbs, Aurora expanded into areas where patients make more and have insurance that pays more.

In early 2010, Aurora opened a $250 million medical center in Summit, where 1% of the families are in poverty. Officials at ProHealth Care fought the new hospital, arguing the beds weren't needed because of its nearby facility. Later that year, Aurora opened a $254 million facility in Grafton, where it touts "home-like patient rooms with private baths" and "extensive landscaping with the area's native plantings."

The facilities were built in the heart of the state's two wealthiest counties.

Like many of the country’s 46.5 million people living at or below the poverty line, John Patton Jr. faces chronic health problems, doesn’t get regular health care and lives in circumstances that make him sicker.

Lillian Thomas of the Pittsburgh Post-Gazette examined the barriers to health and health care for low-income urban Americans through a nine-month Perry and Alicia O’Brien Fellowship in Public Service Journalism at Marquette University. Thomas worked with journalists from the Milwaukee Journal Sentinel and was supported by students from Marquette’s Diederich College of Communication. Future installments in this series will examine the effect of hospital closures and new models for improving health care.

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YES! ANOTHER reason for government to run things in order to make sure things are fair. Surely it is time to forbid the wealthy from going to Mayo's for REALLY good care. How obscene... Cuba is our model now.

Have you ever been to Cuba? I have. In Havana there is a 6-lane road running along the malecón. During rush hour you could cross that road blindfolded without worrying about getting hit. No building in the city of Santa Clara(around 220,000 people) has seen any paint in over 50 years. Cuba is a model all right. It shows how total government control and ownership of everything has utterly failed.

If I had to go out of state for medical care, which I don't since SE Wisconsin has outstanding physicians, I'd go to Cleveland Clinic for cardiac and Scripps La Jolla for anything else. Mayo is a name, not a guarantee nor is Mayo the the ne plus ultra of health care in the US.

Anyone bashing the Cuban medical system seriously needs to see the excellent Michael Moore film, "Sicko." It's sad when working poor Americans have to sneak off to Cuba to obtain affordable health care and especially affordable medications. And why do we still have that silly trade and travel embargo against Cuba anyway? President Kennedy should never have imposed that embargo.

I have not seen the movie nor do I intend to. I have been to Cuba, and I have Cuban friends. Even if Cuba had the best medical system in the world(and they most assuredly do not), I would never live in that society as it exists today.

The embargo was imposed at the behest of Cubans who fled Castro. It remains because of the political power of those Cuban expats. The embargo hardly means a thing to Cubans or non-US citizens. Cuba can and does trade with the rest of the world. A lot of Canadian and European companies have investments in Cuba.

This is so classic, A false premise put forward as fact by the liberal media, and the lib's jump on the bandwagon. When you were "young", you had no idea of what middle class meant, much less how it applied to physicians. And you sure as heck have no information from this story as to their housing situation, so where is your proof of the "mansions". Don't be a media tool. Think about what you read.

Actually most doctors do not make what you think they do. Family practice, internal medicine, psychiatry, pediatrics, and gynecology without obstetrics are all primary care specialties. These are the lowest paying specialties in medicine. While their pay may seem generous to working class and lower to mi range middle class income earners a pay range of $200,000 to $250,000 annually isn't all that high for the schooling and training those doctors received. Four yours of premed, four years of medical school, an internship, and then four years of residency. Sure, residents are paid. But they work long hours and are not paid all that well. Then when these primary care doctors start working full-time they have student loans in excess of $100,000 to repay. And that's if they attended a state university and state medical school both at the in-state resident rate.

Yes, $275 for a five to 10 minute office visit looks excessive and it is. Virtually all primary care doctors in the Milwaukee metro area work for a large to very large physician group practice. And that practice is actually part of the health care "system." A health care "system" exists the once a hospital purchases a physician group practice. What we don't see during that office visit is the battalion sized workforce behind the scenes. Sure we see the medical assistant -- LPNs were phased out at least 25 years ago -- the receptionist, and possibly a phlebotomist who does the blood draw or another lab employee who hands us the urine specimen cup. We don't see the staff who codes claim forms and forwards them electronically to insurance. We don't see the ones who handle preauthorizations of medications because some overpaid bean counter with a bachelors degree at the insurance company thinks he knows what's best for us better than our doctor who's attended medical school and been through residency, we don't see those who credit our accounts when insurance pays, we don't see the billing department, we don't see the contract cleaning service which charges over $20 an hour for labor but pays staff perhaps $8.30 an hour, we may not see maintenance personnel, and more. Yes, there is room for economizing in health care but that's a separate issue.

Milwaukee area health care can become more efficient and less costly. But it's going to require an end to the "arms race" to see who can building the most over-designed and fanciest looking health care palaces. If you look at hospitals and medical clinics designed in the 50's, 60s, and into the mid 1970s you see plain Jane looking, but highly practical structures. It was an era when utilitarian was the word. This is what we need to go back to. No more player grand pianos in the lobby and gleaming walls of glass. That glass costs a fortune to have cleaned. I do not know what it's going to take for health care providers to compete on the basis of price, but if we're not going to have European socialized medicine where the government owns the hospitals, clinics and the like and doctors, nurses and other staff are civil servants or the Canadian-style Medicare for all single payer, then health care needs to act like a business and compete on price.

JR, price competition will come when insurance does not pay for everything when people see exactly what everything costs. Let the market work as it has for Lasik and cosmetic surgery that insurance generally does not pay for.

It doesn't matter. When you invest that much time and money into your career, you call your own shots. Where is the obligation for a banker or a plumber to live in or service the 'hood'. How is demonizing doctors going to change a doctor shortage?

Most doctors working at inner city hospitals and clinics can only dream of owning a Mercedes Benz some day. They're likely working the inner city gig to help reduce their $100,000-plus student loans. They're hoping and praying they do not end up on the gurney in the next Bell Ambulance heading to the Froedtert ER with a gunshot patient. Remember, the north side, northwest side, and near south sides of Milwaukee have as many bullets flying as Beirut did 25 years ago and Baghdad does today. The doctors working at Sinai and inner city clinics are almost certainly family practice, internal medicine, pediatrics, psychiatry and ob/gyn or gynecology without obstetrics. Those are all primary care specialties. They're front-line doctors, but they're also the lowest paid. If they're driving a Mercedes, it's used, at least 6 years old with over 100,000 miles on it and they're making hefty payments on it.

Some stab wounds are treated in Waukesha and doctors treat unreported gun shots in suburbs. Young doctors are not driving Benz's. Should a doctor be paid less than the CEO of Disney. you want good health care or a talking duck, mouse.

Fat cat -- The doctors sewing up knife wounds and removing bullets work at the Froedtert ER. That's the are Level 1 trauma center. That's where MedFlight, and Flight for Life bring in the severely injured when some drunk driver with no insurance T-bones a family car as the family returns home to Oshkosh at midnight. following an all-day outing at Six Flags Great America. The Froedtert ER is the one which comes the closest to what you see on ER reruns on TV. A lot of the work being done in the ER there is done by residents making peanuts while having to pay the interest on their six-figure student loans. Those residents either get around by MCTS and a bicycle or a six-year-old Honda Civic with 120,000 miles on it. I once was guilty of thinking doctors are overpaid. Yes, some specialists do bring home some huge salaries. But primary care is not all that well paying, especially when one considers the schooling and training. What front line doctors make is not the cause of our nation's heath care affordability crisis. Limiting doctor pay will only make this worse. I support single-payer, but I know not everyone does. I can say this. The full socialized medicine system of Great Britain where the hospitals and clinics are owned by the National Health Service and doctors, nurses, receptionists, lab workers, blood draw techs, imaging technologists, etc. are civil servants is not going to work in this country. At the same time, the status quo is broken and needs to be dumped. The Affordable Care is not working, either. I do challenge the Republicans to actually offer a plan for a change instead of trying to shoot down everything those on the left and in the center propose.

JR, the GOP has offered many ideas. They continue to offer many ideas. Now that the Democrats are getting close to an election where they will have to defend their support of an unpopular ACA, they are starting to listen. Obama is even changing many things unilaterally.

I would like to see a series of single-issue bills passed to try to repair the ACA.

gee, what a shocking story. new liberal template that is coming, demonize doctors salaries, dictate who doctors have to see and where they have to see them. lets create an even larger shortage of doctors in this state and country. you liberals really are morons.

Garis is spot on. That story is about as researched as a Graham Zielinski tweet. You mean "facts" like:

"Think of a child with asthma living in a mold-filled apartment; a man with an infected foot living on the streets and sleeping in his dirty, wet shoes; or a diabetic without a refrigerator to store her insulin."

While that is some dynamic prose, it is a melodrama without specifics. Get a clue. Stories like this are written to support the liberal push to single payer health care. Obamacare was just a step and the administration wants to move this to the "inevitable" stage before Obama's term is done.

Circling. I have met people like the man living on the streets with an infected foot. Instead of money I have handed people like these food. Food as in I had just eaten at Subway and purchased a foot-long sub for the $5 special promo price and only eaten half. I gave the fellow living on the street the other half I was going to take home. Yes, he had a drinking problem -- addicted to cheap beer or booze. However, handing someone like him food is far better than giving him booze money. This man is dead now. However, he did not trust homeless shelters and had other bad experiences with institutions and the like. No one should have to live on the streets of Milwaukee as though this is Calcutta. Not all living on the streets are alcoholics or drug addicts. Many are living with treatable mental illnesses and at one point or another were deinstitutionalized. That sounded like a great plan back in 1978. And it could have been. The problem is the funding for local clinics, especially sliding scale to see MSWs and MDs (psychiatrists) as well as affordable meds never materialized in adequate amounts. Somehow building more nuclear bombs and one mega priced weapons system after another in the 1980s was more appealing to President Reagan. There has never been a president more out of touch with the average American than Reagan. Even George W. Bush had a much better clue as what life was like for an average American. Under Reagan our homeless population multiplied like dandelions in May.

Rural communities need competent Doctors & Hospital Administrators more than Urban blight areas. Take Burnett County, which ranks 71 out of 72 in Clinical Care among WI counties. BC has a beautiful new Hospital, but incompetent Doctors & CEO. We need a large progressive Healthcare company to take over & improve BC's Clinical Care ranking.

The price you pay for peace & quiet, is living far from 'services' of any kind... Most rural/exurban folks just (gasp) drive to the near-suburbs for their medical needs (and for work, and to shop, etc)...

Good points, Dave. I lived in Columbus, Wis. for 9.5 years. I first moved there to take a job as editor of the local weekly newspaper. After that gig ended, I stayed living in Columbus, but working various jobs for years in Madison and Sun Prairie. The rent by Madison standards was unbelievably low. However, I burned a lot of gas (driving a Saturn SL with manual transaxle) driving back and fourth. That also put a lot of miles and wear and tear on the car. Columbus has a nice, rural/exhurban (Madison) hospital. Not all the latest and greatest gizmos like MRI scanners, but those do come in once a week or so on a truck. There were a number of primary care family practice or internal medicine doctors and at least one ob/gyn to take care of the local needs. But when I would be referred to a specialist, it usually meant a drive to somewhere in downtown Madison or a Madison east side multi-specialty clinic. Or sometimes a specialist might have office hours one day a week at the Columbus hospital. Yes, Columbus offered peace and quiet. But it was either a 20 minute drive to Beaver Dam, 35 minute drive to Portage or 25 minute drive to the far east side of Madison plus driving time elsewhere in Madison. If I could do it over, I would have moved to Sun Prairie after the newspaper gig ended.

Bob -- Large and very large physician group practices sound really great on paper and even better when you see their slick ads on TV or in a newspaper/magazine, or hear them on radio. But that's where the benefits of a large or very large physician group practice end. Those ads cost money, lots of money. Money first goes to the ad agency which creates the ads. Then money goes to the newspaper, radio stations and TV stations to run those ads. Large and very large physician group practices today love really nice looking often cookie cutter on the inside large clinics. Those clinics are either leased office space or mortgage payments need to be made. A cleaning service needs to be hired. Those large clinics are not cleaned by one person working part time. Those costs are starting to add up, aren't they? Guess who pays for all those costs? Insurance companies and patients. If you get to see some small market daily or weekly newspapers, you might sometimes see small claims courts case listings published. Guess who the largest filers of small claims court cases are in most counties? Credit card companies? No. Usually debtors either settle, work out a payment plan or file bankruptcy. If you answered hospitals and medical clinics, you are correct. The once your local doctor in solo or small group practice sell his/her/their practice to the large or very large group, the cost of office visits goes up overnight. Your doctor and his/her staff are now instructed to refer you to specialists only within the group and to labs on in the group. That is unless you speak up and ask for a lab order you can take elsewhere if that is what your insurance requires.

Medical care is expensive. It costs money. Professionals like doctors prefer to get paid for their work. Poor people by definition don't have money. If poor people don't pay then you and I have to pay. It's common sense.

Are you sure ya didn't grow up in backwards Texas with those brilliant minds of G.W. Bush & Gov. Rick Perry? Your logical thinking about healthcare is that of the idiots of the GOP. When you're a Senior, just tell your rich Doctor NOT to bill Medicare, you want to pay for the $150,000 bypass surgery yourself.

I'm glad that you're not my uncle Bob, because then I'd have an idiot in the family! Maybe instead of whatever liberal junk you're reading now, you should spend some time reading some actual facts and figures. No, I'm not talking about just conservative stuff either, but just plain facts like the last US census for one example. Then you'd see that "backward Texas" is actually BOOMING TEXAS!!! Dallas is now the fourth most populous metro area in the USA and Houston is right behind, both are growing fast.

Did you see the recent articles about how Toyota recently announced it was undertaking the massive and expensive job of moving its US headquarters out of your lib run for many years paradise-California and moving it to-TEXAS!!!!

You're not booming in Texas so much now are you, Dean. With the crash of the oil market it seems you and your ilk aren't looking so good now. It seems your wealth really wasn't due to any superiority of thought or morality at all. It seems it had a lot to do with controlling the oil markets. Truth is we would have had suitable public transportation nationwide years ago if it were not for the rich oilmen of the US in concert with the Arabs they profess to hate so much. They make sure we remain a car dependent society to prop up their earnings. Free market my a**. You are the fools who still believe in "trickle down economics." Giggle...how dumb is that?

@GOPequalsgreed-Wow, you're comment here, along with your screen name makes me wonder if there's some little secret GOP side operation where they have some staffer or intern posting comments on sites like this that just SO STUPID and totally senseless that they're hoping to create the impression for independents and even for some moderate Dems, that the Democrat party has now been hijacked by some real nutjobs and should just be written off completely!

How does anyone even attempt to refute such total nonsense???

I will take a shot at your screen name though! Take a look at REALITY some time soon and look at who has not just doing well since Jan 20, 2009, but who has been doing exceptionally well-its not tough at all, since other than this one single group, the rest of the USA hasn't been doing well at all! The ONLY group that's been great under Obama is the SUPER RICH!!!! Mainly the Wall Street types, who don't produce anything!

It is amazing in our system how quickly one can go from "well covered" to "cannot pay". Think of pre existing conditions as a qualifier and ask anyone that was excluded in the past how fair that was. .

It is easier for a minority to get free medical school than a person from Cedarburg, so why don't minority doctors want to work in the inner city? Because they worked hard to get out of the inner city!

Go figure: Hospitals move out of places where they bleed money, to places where the customers actually PAY FOR THE PRODUCT THEY USE rather than stiffing the provider with the bill or relying on Medicaid....

Sure, Keeway. And when you get a brain tumor or suffer a stroke nobody will be there to care for you. If you think all you need to do is eat well and exercise to avoid ever needing a doctor you just might be in need of some basic psychiatric care yourself right now.